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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

KDHL-AWZT5R

FACILITY NAME Chestnut House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # PNEL-8A2M9P
FACILITY ADDRESS 4576 55B St			FACILITY PHONE (604) 946-0401
CITY Delta	POSTAL CODE V4K 3W5		MANAGER William Brunke

INSPECTION DATE March 15, 2018	ADDITIONAL INSP. DATE (multi-day) March 19, 2018		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4.5
ARRIVAL 12:30 PM	DEPARTURE 02:30 PM	ARRIVAL 11:30 AM	DEPARTURE 02:00 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection. The following areas were reviewed: · Licensing · Physical Facility · Staffing · Polices & Procedures · Care & Supervision · Hygiene and Communicable Disease Control · Medication · Nutrition and Food Services · Program · Records and Reporting As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation. Visit the CCFL website at www.fraserhealth.ca/residentialcare for: · Additional resources and · Links to the Legislation (CCALA & RCR)

Contraventions

Previous Inspection - Not Applicable

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act. Observation: The Medication Safety and Advisory Committee policies and procedures does not have a date of review by the which the committee reviews policy to meet the intent of this regulation, eventhough the manager reviews the policy anually. The policy does not state the review is solely by the manager yearly. Appendix 1 states "Any and all exceptions to this policy and procedures must be in writing, including a review/end date and be authorized by the presribing physician, the Pharmacist and Safety Committee member". In addition, the authorization for the policy and procedures has not been signed by the manager, pharmacist or the consulting psychiatrist as required Corrective Action(s): Ensure process for review is established as required. Date to be Corrected: April 20, 2018

Comments

Licensing would like to acknowledge: - Renovation plan was submitted to Licensing prior to the routine inspection. The licensee appears to have an appropriate plan in place to ensure that there is no increased risk to persons in care. - The manager has a system in place for monitoring and oversight to ensure any areas for concern are identified and followed up in a timely and appropriate manner.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Apr 20, 2018

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